Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit.

AIM: To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes. MATERIALS AND METHODS: Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022. RESULTS: Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002). CONCLUSIONS: The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

National audit of seven-day working care in radiology.

OBJECTIVES: To evaluate the extent to which our current provision of diagnostic and interventional radiology services matches existing clinical demand and future government proposals as set out in the Royal College of Radiologists published guidance on providing seven-day acute care. METHODS: In June 2018, all UK radiology department audit leads were sent a questionnaire designed to assess compliance for each standard of the Royal College of Radiologists published guidance on providing seven-day acute care. RESULTS: 135 hospitals (68%) responded. Of those that responded, 96% of departments have a diagnostic radiologist rota for clinicians to discuss acute cases and review imaging and 48% of departments do not have a fully staffed consultant rota 24 h a day, seven days a week for interventional radiology. There is significant variance in MRI radiographer availability within departments, ranging from 18.8% during Saturday/Sunday evening/overnight up to a maximum of 63.9% during Saturday daytime. 11% of departments participate in a regional out of hours cross-organisation reporting rota. 40% of departments have no 24/7 RIS technical support and 34% have no PACS technical support out of hours. CONCLUSION: There is a wide variation in practice across radiology departments in the UK. Although there are some standards that the majority of hospitals are achieving, there is a significant short-fall in fundamental aspects of providing acute seven-day care. The multifactorial nature in which these problems have arisen means there is no easy solution to combat these issues. There is a requirement for significant investment and political commitment to improve staffing and infrastructure in order to address the current situation. ADVANCES IN KNOWLEDGE: A UK wide evaluation of the current provision of seven-day working in radiology showing 54% of hospitals do not have a UK working-time regulations compliant Interventional radiology rota, severe lack of availability of acute MRI out of hours and significant deficiencies in providing technical support out of hours. A sustainable and efficient seven-day service is currently not being provided.

Imaging in myeloma: a Royal College of Radiologists national survey of current imaging practice.

AIMS: To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites). MATERIALS AND METHODS: All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed. RESULTS: One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training. CONCLUSION: Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

Royal College of Radiologists national audit evaluating the provision of imaging in the severely injured patient and compliance with national guidelines.

AIM: To evaluate the provision of imaging in severely injured patients and com pliance with national guidelines. MATERIALS AND METHODS: Two data collection tools were sent to all Royal College of Radiologist audit leads in radiology departments with an emergency department throughout the UK. The first focused on configuration of radiology departments, number of patients scanned for major trauma and service configuration for major trauma. The second focused on reporting times for 30 patients scanned for major trauma. RESULTS: Eighty-five out of 191 (45%) eligible departments responded: 16 (19%) from major trauma centres, 52 (61%) from trauma units and 17 (20%) from other hospitals with an emergency department. Data were collected for 2,161 scans: 450 from major trauma centres, 1,400 from trauma units and 311 from emergency departments. Seven hundred and eighty-four (36%) scans were performed in hours and 1361 (63%) out of hours. Two hundred and forty (11%) scans had a primary survey report documented, of which 53 (22%) were unavailable to clinicians after 20 minutes. Time to final consultant report was within 1 hour for 1,033 (48%) scans and within 2 hours for an additional 540 (25%) scans. 34/85 (40%) departments have registrars first on call for major trauma who report scans out of hours and have a consultant final report the next day. CONCLUSIONS: This study highlights significant deficiencies in care and imaging of severely injured patients within major trauma centres and trauma units. Infrastructure and staffing have been underfunded and under resourced to meet rapidly changing best practice requirements in the management of major trauma.

Radiotherapy Management of Muscle Invasive Bladder Cancer: Evaluation of a National Cohort.

AIMS: With the failure to improve outcomes of patients with bladder cancer over the last 30 years, this study was developed to benchmark contemporary UK radiotherapy practice for the management of muscle invasive bladder cancer (MIBC) against published national guidance. MATERIALS AND METHODS: All UK radiotherapy centres were invited to complete a questionnaire for each patient with MIBC starting bladder radiotherapy over a 16-week period from December 2016. RESULTS: Sixty-nine per cent (41/59) of UK radiotherapy centres completed a detailed questionnaire for 508 patients. The median age was 78 years and 64% (n = 323 patients) had stage II or III disease. Treatment intent was radical in 54% (n = 275). From transurethral resection of the bladder tumour, patients waited 57 days before starting neoadjuvant chemotherapy (NAC) (interquartile range 46-72 days). Patients who had radical radiotherapy as their first definitive treatment waited a median of 82 days (interquartile range 62-105 days). NAC was considered in 66% (n = 182) of all radical cases and given in 43% (n = 119). Concurrent radiosensitisation (CRT) was considered for 53% (n = 146) and delivered in 40% (n = 109) of patients. The most common fractionation was 55 Gy/20 fractions/4 weeks in 49% (n = 134) for radical patients and 36 Gy/6 fractions/6 weeks in 25% (n = 57) for palliative patients. CONCLUSION: This is the largest multicentre prospective study to define contemporary management of MIBC in patients receiving radiotherapy within the UK. The population studied is the oldest described to date. Timelines to starting definitive treatment confirm an urgent need to streamline the pathway. An increasing use of NAC is described, although the penetrance of CRT is disappointingly low. Areas for improvement with regards to the delivery and quality of radiotherapy have been identified. The detail within this study can be used to inform practice and future trial design, ultimately with the aim of improving outcomes for patients with MIBC.

RCR audit of compliance with UK guidelines for the prevention and detection of acute kidney injury in adult patients undergoing iodinated contrast media injections for CT.

AIM: To determine radiology departmental compliance with current UK guidance on contrast-induced acute kidney injury (CI-AKI) and to provide data on the incidence of clinically significant post-contrast AKI (PC-AKI) in computed tomography (CT) practice. MATERIALS AND METHODS: A questionnaire was sent to all UK acute National Health Service (NHS) providers (NHS boards in Scotland, local health boards in Wales, NHS trusts in England and health and social care trusts in Northern Ireland) to assess compliance of provider protocols with current UK guidelines for the prevention, recognition, and management of CI-AKI. Audit data were collected for 40 consecutive fit outpatients and 40 consecutive acutely unwell patients/inpatients from hospitals within each participating provider to assess clinical compliance. RESULTS: Eighty-nine of 172 (52%) health service providers responded, and data on 7,159 contrast-enhanced CT examinations were provided. Compliance with guidelines was poor with wide variation in clinical practice. The observed incidence of clinically significant (requiring treatment or resulting in death) PC-AKI was zero in 3,590 outpatients, although two patients developed AKI due to other causes (sepsis and progressive malignancy). Fourteen out of 3,569 (0.4%) patients in the inpatient group developed clinically significant PC-AKI, and a further 17 patients were identified who met the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI (Electronic Supplementary Material Appendix S1), but did not require active treatment, giving an overall incidence of AKI of 0.9%. In patients at high risk due to impaired renal function prior to the scan, there was no difference in the median serum creatinine (SCr) before and after contrast medium administration in either group. CONCLUSION: Health service provider protocols and clinical practice demonstrate poor compliance with current UK guidance on CI-AKI. A very low incidence of PC- AKI was demonstrated.

Audit of radiology communication systems for critical, urgent, and unexpected significant findings.

AIM: To determine the compliance of UK radiology departments and trusts/healthcare organisations with National Patient Safety Agency and Royal College of Radiologist's published guidance on the communication of critical, urgent, and unexpected significant radiological findings. MATERIALS AND METHODS: A questionnaire was sent to all UK radiology department audit leads asking for details of their current departmental policy regarding the issuing of alerts; use of automated electronic alert systems; methods of notification of clinicians of critical, urgent, and unexpected significant radiological findings; monitoring of results receipt; and examples of the more common types of serious pathologies for which alerts were issued. RESULTS: One hundred and fifty-four of 229 departments (67%) responded. Eighty-eight percent indicated that they had a policy in place for the communication of critical, urgent, and unexpected significant radiological findings. Only 34% had an automated electronic alert system in place and only 17% had a facility for service-wide electronic tracking of radiology reports. In only 11 departments with an electronic acknowledgement system was someone regularly monitoring the read rate. CONCLUSION: There is wide variation in practice across the UK with regard to the communication and monitoring of reports with many departments/trusts not fully compliant with published UK guidance. Despite the widespread use of electronic systems, only a minority of departments/trusts have and use electronic tracking to ensure reports have been read and acted upon.

The Royal College of Radiologists' audit of prostate brachytherapy in the year 2012.

AIMS: This audit provides a comprehensive overview of UK prostate brachytherapy practice in the year 2012, measured against existing standards, immediately before the introduction of new Royal College of Radiologists (RCR) guidelines. This audit allows comparison with European and North American brachytherapy practice and for the impact of the RCR 2012 guidelines to be assessed in the future. MATERIALS AND METHODS: A web-based data collection tool was developed by the RCR Clinical Audit Committee and sent to audit leads at all cancer centres in the UK. Standards were developed based on available guidelines in use at the start of 2012 covering case mix and dosimetry. Further questions were included to reflect areas of anticipated change with the implementation of the 2012 guidelines. Audit findings were compared with similar audits of practice in Europe, the USA and Latin America. RESULTS: Forty-nine of 59 cancer centres submitted data. Twenty-nine centres reported carrying out prostate brachytherapy; of these, 25 (86%) provided data regarding the number of implants, staffing, dosimetry, medication and anaesthesia and follow-up. Audit standards achieved excellent compliance in most areas, although were low in post-implant dosimetry and in post-implant scanning at 30 days. CONCLUSION: This audit provides a comprehensive picture of prostate brachytherapy in the UK in 2012. Patterns of care of prostate brachytherapy are similar to practice in the USA and Europe. The number of prostate brachytherapy implants carried out in the UK has grown significantly since a previous RCR audit in 2005 and it is important that centres maintain minimum numbers of cases to ensure that experience can be maintained and compliance to guidelines achieved.

A royal college of radiologists national audit of radiotherapy in the treatment of metastatic spinal cord compression and implications for the development of acute oncology services.

AIMS: To audit the current use of radiotherapy in UK cancer centres for the treatment of metastatic spinal cord compression against national standards that seek to optimise functional and quality of life outcomes. MATERIALS AND METHODS: A Royal College of Radiologists prospective national audit of patients treated with radiotherapy in UK cancer centres was carried out over a 3 month period between September and December 2008, with a repeat audit carried out in August 2012. RESULTS: Five hundred and ninety-six cases were received from 42 cancer centres (74%) in 2008, with data from 323 cases received from 52 (90%) centres in 2012. Ninety-three per cent (358) of patients had a diagnostic magnetic resonance imaging scan carried out within 24 h of referral for radiotherapy in 2008 compared with 205 patients (97%) in 2012. One hundred and eleven (32%) good prognosis patients were discussed with spinal surgeons; only 10 good prognosis patients were recorded as proceeding to surgery in 2008. This improved in 2012, with 94 (41% of good prognosis patients recorded as having been discussed with nine proceeding to surgery). Sixty-nine per cent of paraplegic patients in 2008 received multiple fractions of radiotherapy, which was similar to 2012 when 62% received more than a single fraction. A metastatic spinal cord compression co-ordinator was available in just over 50% of cases (164/323) and was involved in patient management in 26% of cases in 2012. CONCLUSION: Despite level 1 evidence of the superior functional outcome and survival benefit for surgery, few good prognosis patients were recorded as having been discussed with surgeons and even fewer proceeded to surgery.

Staging cancer of the uterus: a national audit of MRI accuracy.

AIM: To report the results of a nationwide audit of the accuracy of magnetic resonance imaging (MRI) staging in uterine body cancer when staging myometrial invasion, cervical extension, and lymph node spread. MATERIALS AND METHODS: All UK radiology departments were invited to participate using a web-based tool for submitting anonymized data for a 12 month period. MRI staging was compared with histopathological staging using target accuracies of 85, 86, and 70% respectively. RESULTS: Of the departments performing MRI staging of endometrial cancer, 37/87 departments contributed. Targets for MRI staging were achieved for two of the three standards nationally with diagnostic accuracy for depth of myometrial invasion, 82%; for cervical extension, 90%; and for pelvic nodal involvement, 94%; the latter two being well above the targets. However, only 13/37 (35%) of individual centres met the target for assessing depth of myometrial invasion, 31/36 (86%) for cervical extension and 31/34 (91%) for pelvic nodal involvement. Statistical analysis demonstrated no significant difference for the use of intravenous contrast medium, but did show some evidence of increasing accuracy in assessment of depth of myometrial invasion with increasing caseload. CONCLUSION: Overall performance in the UK was good, with only the target for assessment of depth of myometrial invasion not being met. Inter-departmental variation was seen. One factor that may improve performance in assessment of myometrial invasion is a higher caseload. No other clear factor to improve performance were identified.

Substantial improvement in UK cervical cancer survival with chemoradiotherapy: results of a Royal College of Radiologists' audit.

AIMS: To compare survival and late complications between patients treated with chemoradiotherapy and radiotherapy for locally advanced cervix cancer. MATERIALS AND METHODS: A Royal College of Radiologists' audit of patients treated with radiotherapy in UK cancer centres in 2001-2002. Survival, recurrence and late complications were assessed for patients grouped according to radical treatment received (radiotherapy, chemoradiotherapy, postoperative radiotherapy or chemoradiotherapy) and non-radical treatment. Late complication rates were assessed using the Franco-Italian glossary. RESULTS: Data were analysed for 1243 patients from 42 UK centres. Overall 5-year survival was 56% (any radical treatment); 44% (radical radiotherapy); 55% (chemoradiotherapy) and 71% (surgery with postoperative radiotherapy). Overall survival at 5 years was 59% (stage IB), 44% (stage IIB) and 24% (stage IIIB) for women treated with radiotherapy, and 65% (stage IB), 61% (stage IIB) and 44% (stage IIIB) for those receiving chemoradiotherapy. Cox regression showed that survival was significantly better for patients receiving chemoradiotherapy (hazard ratio=0.77, 95% confidence interval 0.60-0.98; P=0.037) compared with those receiving radiotherapy taking age, stage, pelvic node involvement and treatment delay into account. The grade 3/4 late complication rate was 8% (radiotherapy) and 10% (chemoradiotherapy). Although complications continued to develop up to 7 years after treatment for those receiving chemoradiotherapy, there was no apparent increase in overall late complications compared with radiotherapy alone when other factors were taken into account (hazard ratio=0.94, 95% confidence interval 0.71-1.245; P=0.667). DISCUSSION: The addition of chemotherapy to radiotherapy seems to have improved survival compared with radiotherapy alone for women treated in 2001-2002, without an apparent rise in late treatment complications.

Radiotherapy in England in 2007: modelled demand and audited activity.

AIMS: Modelling of demand has indicated substantial underprovision of radiotherapy in England. We have used national audit data to understand the differences between theory and practice. MATERIALS AND METHODS: We used a web-based tool to collect data on all National Health Service patients in England starting a course of radiotherapy in the week commencing 24 September 2007. We also collected information on cancer site, so that patients could be triaged into the 22 categories used by the National Radiotherapy Advisory Group (NRAG). RESULTS: In England, excluding skin cancer other than melanoma, 2114 patients were prescribed 27,420 fractions during that week. Comparison of the audit data with the NRAG model showed that the shortfall in provision was a mixture of a lack of access (67%) and reduced fractionation (33%). The largest contributions to the overall gap were seen in the treatment of cancers of the breast (6%) (modelled at 15 fractions), head and neck (10%), lung (28%) and prostate (14%), together accounting for 58% of the difference. Others (including sarcoma and unknown primary) accounted for 19% of the difference. Limited access to radiotherapy for patients with stomach and pancreatic cancer contributed 10% and reduced fractionation for oesophageal cancer accounted for 6% of the overall gap. Fewer patients than expected were treated for rectal cancer, but they received 25 fraction regimens rather than short-course preoperative treatment. Patients with leukaemia and cancers of the brain, colon, corpus uteri and ovary received radiotherapy more often than expected, but because they are relatively rare none of these had an overall impact exceeding 1.2% of the gap in provision. CONCLUSIONS: This audit confirms the underprovision of radiotherapy in England and shows that it is largely accounted for by low access rates of 37% rather than the 50% accepted in the literature. In consequence we estimate that 33 881 patients (13.9%) of the 243 748 patients diagnosed with cancer in England during 2006/2007 did not receive the radiotherapy we would have expected. Some of this gap in provision may be accounted for by differences in stage and performance status, which limit treatment options, for example in lung cancer. The NRAG model should be updated to take account of new data from this and other national audits, to ensure that it describes the stage and performance status of English patients and is sensitive to the range of professional opinion about treatment options. This will be essential for long-term planning as cancer incidence increases over the next decade, but it does not weaken the conclusion that there is a substantial current shortfall to be addressed immediately to improve timely access to treatment and thus the outcomes of therapy. As more resource becomes available, it should be possible to consider changing dose fractionation to comply with evidence-based practice and national guidelines from the National Institute for Health and Clinical Excellence and other bodies without disadvantaging patients by increasing waiting times.

Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation.

AIMS: Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities. MATERIALS AND METHODS: We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority. RESULTS: Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0-62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2-23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased (r=0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy (r=-0.820). CONCLUSIONS: There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618-5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners.

Waiting times for systemic cancer therapy in the United Kingdom in 2006.

This audit was conducted to measure waiting times for systemic cancer therapy across the United Kingdom. All patients, aged 16 years or older, commencing their first course of systemic therapy between 13 November and 19 November 2006 were eligible for inclusion. Data on 936 patients from 81 hospital sources were collected. Systemic therapy is largely given in compliance with national waiting time targets. In terms of the Joint Council for Clinical Oncology (JCCO) targets, 84% of patients commence treatment within 21 days and 98% of patients complied with the Department of Health target that treatment should follow within 31 days of the decision being agreed with the patient. Only 76% complied with the Department of Health 62-day target from GP referral to first definitive treatment. However, the date of urgent referral by the GP was not submitted for most patients in our survey, leaving a sample of only 84 out of 936 patients (9% of total) suitable for this analysis. There was only a 3- to 5-day difference between the waiting times for systemic therapy for patients categorised as urgent compared with routine. Locally agreed definitions had little impact on patients' priority for treatment. This audit has established a baseline measurement of waiting times for systemic therapy across the United Kingdom. The continuing introduction of novel therapies is likely to have a significant effect on the service and we recommend that service managers model the likely impact on resource requirements. In addition, urgent treatment should be clearly defined as that required within 24 h (maximum 48 h) to avoid the risk of clinical deterioration, particularly in patients with acute leukaemia, lymphoma or germ cell tumour.